Metin Kapan

COLOR: A Randomized Clinical Trial Comparing Laparoscopic and Open Resection for Colon Cancer

Background: Laparoscopic surgery has proven to be safe and effective. However, the value of laparoscopic resection for malignancy in terms of cancer outcome can only be assessed by large prospective randomized clinical trials with sufficient follow-up. Methods: COLOR (COlon carcinoma Laparoscopic or Open Resection) is a European multicenter randomized trial which has started in September 1997. In 24 hospitals in Sweden, The Netherlands, Germany, France, Italy and Spain, 1,200 patients will be included. The primary end point of the study is cancer-free survival after 3 years. Results: Within <2 years, more than 540 patients have been randomized for right hemicolectomy (45%), left hemicolectomy (10%) and sigmoidectomy (45%). 33 patients (6%) were excluded after randomization. The accrual rate is approximately 25 patients/month. Current survival rates for the whole study group are: stage I: 95%, stage II: 98%, stage III: 93%, stage IV: 64%. For all patients with stage I disease, the mortality was not cancer related. Conclusions: Although laparoscopic surgery appears of value in colorectal malignancy, results of randomized trials have to be awaited to determine the definitive place of laparoscopy in colorectal cancer. Considering the current accrual rate, the COLOR study will be completed in 2002.

Primary Splenic Hydatidosis

Background: A hydatid cyst is still a serious health problem in endemic areas. Invasion of the spleen is rare in hydatid disease. In the medical literature, reports about isolated splenic hydatidoses are quite rare. Also there is not a consensus about the way of treatment. Methods: Between 1978 and 2000, in our clinic approximately 900 patients were operated on for an abdominal hydatidosis; 850 of these patients were treated for a hepatic hydatidosis and 14 patients for an isolated splenic hydatidosis. Six (42.8%) of the latter patients were male and 8 (57.1%) were female. The mean age of the patients was 47.14 ± 4.9 (range 17–72) years. Ten patients (71.4%) presented with a painful mass in the left upper quadrant of the abdomen, and the other 4 patients (28.5%) were asymptomatic and were diagnosed incidentally. Results: All of the patients underwent elective splenectomy. There was no mortality, but complications occurred in 4 (28.5%) patients. The period of hospitalization ranged from 7 to 17 days with a mean of 9.8 days. 1 patient died from an acute myocardial infarction during the 2nd postoperative year, and 1 patient died as a consequence of a traffic accident during the 5th postoperative year. Nine patients, after follow-up periods of between 2 and 14 years, are living free from disease. No recurrence occurred in any of them. In the remaining 3 patients, long-term follow-up could not be maintained. Conclusions: A hydatid cyst must be included in the differential diagnosis of cystic lesions of the spleen. A splenic hydatid cyst should be treated surgically due to the high risk of a rupture, and the ideal procedure in adulthood is standard splenectomy.

Postoperative recurrence in hepatic hydatid disease.

Recurrence of hepatic hydatid disease is still a serious problem in endemic areas like our country. In this study, we present the causes and management of recurrences after surgical therapy of the hepatic hydatid cysts. Hepatic hydatid cyst patients treated surgically and followed afterward at Istanbul University, Cerrahpasa Medical Faculty, Department of General Surgery between January 1998 and January 2003 were evaluated retrospectively. During this period, 172 primary patients with hepatic hydatid disease were attended to at our clinic. Morbidity and mortality rates for this series were 5.8% and 0.58%, respectively. Recurrence rate was 4.65% during the follow-up period of 60.5 months (range, 25-84 months). Primary causes of recurrence were thought to be unnoticed cysts with exophytic development due to inadequate incision and exposition and spreading of the disease during conservative operative interventions. It is concluded that selection of the proper incision allowing complete exposition, and performance of pericystectomy in solitary, peripherally located cysts prevent recurrence.

Gastric duplication cyst.

Background/Aim: The aim of this study is to evaluate the diagnostic and therapeutic difficulties of gastric duplication cysts. Methods: A 38-year-old female patient presented with dyspepsia and repeated episodes of epigastric pain. She was operated with the diagnosis of pancreatic pseudocyst according to her US and CT scans, and found to have a gastric duplication cyst. A cyst about 80×80 mm, localized on the posterior wall of the corpus of the stomach close to the fundus, was dissected from the surrounding tissues and partially from the gastric wall. The cyst did not have muscle layer on the common wall with the stomach, so the cystic mucosa was stripped away from the gastric muscle layer. The gastric lumen was not entered. Results: Although gastric duplication cysts do not have specific symptoms and signs, CT, MR and endoscopic ultrasonography may help the preoperative diagnosis, but the diagnosis is usually confirmed at laparotomy. Needle aspiration may cause complications. Conclusion: Because of the complications that may occur after needle aspiration and malignant potential of the tissue, the treatment of these cysts is surgical.

Comparison of PTFE, pericardium bovine and fascia lata for repair of incisional hernia in rat model, experimental study

Incisional hernia is a frequent complication of abdominal surgery developing in 11–20 % of patients undergoing an abdominal operation. Regarding morbidity and loss of manpower, incisional hernias continue to be a fundamental problem for surgeons. In this experimental study, three commonly used mesh materials (Goretex PTFE; Tutoplast Fascia lata; Tutopatch Pericardium bovine) were compared according to effectiveness, strength, adhesion formation, histological changes, and early complications. Three groups, each consisting of 14 rats, have been formed as group A: polytetrafluoroethylene (PTFE), group B: pericardium bovine and group C: fascia lata. Evaluations were achieved at the end of the first and second postoperative week, respectively. Adhesion formation, wound maturation, bursting pressure, and tensile strength were evaluated. No statistically significant difference regarding adhesion formation was observed between groups although adhesion formation was less significant in PTFE and pericardium bovine groups than in the fascia lata group. Bursting pressure and tensile strength values were significantly higher in PTFE group than in the fascia lata group (P <0.05). No statistically significant difference was observed between groups regarding wound maturation. In this experimental model, PTFE and pericardium bovine were found to be superior to fascia lata in abdominal wall repair.

Ectopic Thyroid in the Abdomen: Report of a Case

Ectopic thyroid tissue can be seen anywhere along the path of the descending glands, but it is rarely seen in the abdominal cavity. An ectopic thyroid was encountered incidentally in the pancreas of a 50-year-old woman who underwent a bilateral truncal vagotomy and pyloroplasty for a duodenal ulcer. There were no signs or symptoms of a thyroid tumor.

Partial Fistulotomy and Modified Cutting Seton Procedure in the Treatment of High Extrasphincteric Perianal Fistulae

Aim: In our prospective study the method of partial distal fistulotomy and modified cutting seton for high extrasphincteric perianal fistulae is discussed. Methods: 10 patients (9 males and 1 female) with high extrasphincteric perianal fistulae were treated with partial distal fistulotomy and modified cutting seton. Four or five threads were introduced through the tract; one was tied tightly at the end of the operation, others were tightened every 10th day. While the tied thread cut the tissue, the others drained the tract. The follow-up period ranged from 3 months to 9 years. Results: None of the patients developed major fecal incontinence. 2 of the 10 patients complained of incontinence due to flatus. Conclusion: Distal fistulotomy and modified cutting seton can be used in perianal fistulae with high anal or rectal opening, because it combines the effects of both cutting and loose setons and because the postoperative results regarding continence are satisfactory.

Totally laparoscopic pericystectomy in hepatic hydatid disease.

Hepatic hydatid disease is still a commonly seen problem in endemic areas as well as in our country. There is a wide spectrum of therapeutic modalities ranging from simple medical treatment to radical liver resection. Progress in laparoscopic procedures made it possible to consider laparoscopic approaches in selected patients with hepatic hydatid disease. The current laparoscopic approach seems to be limited to cystotomy and drainage. There are fewer reports on hepatic resections or pericystectomy in the literature. In this article we present a case of laparoscopic pericystectomy performed in a selected patient.

Simultaneous Rupture of the Liver and Spleen in a Patient on Warfarin Therapy: Report of a Case

Although there are many reports describing spontaneous rupture of either the spleen or the liver, the simultaneous rupture of both organs is a rare event, especially during anticoagulant therapy. We report a case of spontaneous rupture of the spleen and liver in a patient on warfarin therapy for deep venous thrombosis.

Effects of nimodipine and pentoxyfylline in prevention of hepatic ischemic damage in rats at normal and hypothermic conditions

Hepatic ischemia should be considered in serious liver injury, liver tumor resection and liver transplantation. There are other conditions that decrease hepatic blood flow and cause hepatic ischemia, such as hemorrhagic shock, sepsis, hepatic artery ligation, trauma, and certain vascular lesions. In this study, effects of nimodipine (a calcium channel blocker) and pentoxyfylline (a derivative of methylxanthine) on duration and degree of hepatic ischemia in rats at normothermic and hypothermic conditions are investigated. This study was performed on 6 groups of Wistar Albino type rats, each group consisting of 7 rats. Groups were separated into normothermic (A) and hypothermic (B) conditions AI-Control group, AII-Nimodipine group and AIII-Pentoxyfylline group, B IV-Control group, BV-Nimodipine group and BVI-Pentoxyfylline group respectively. After hepatic pedicle occlusion lasting 45 min, blood samples were drawn from the rats for evaluation of alanine aminotransferase (ALT), aspartate transaminase (AST) and lactate dehydrogenase (LDH) values. Moreover, hepatic biopsies were taken to assess pathological changes under electron microscopy. These changes were evaluated through a grading system. As a result; it has been shown that both nimodipine and pentoxyfylline delayed effects of hepatic ischemia in a statistically significant manner in comparison with the control group and these effects were found to be more significant in hypothermic conditions.